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Menopause is when a woman's menstrual periods stop completely. It signals the end of the ovaries releasing eggs for fertilization. A woman is said to have gone through menopause when her menses have stopped for an entire year. Menopause generally occurs between the ages of 45-55, although it can occur as early as the 30s or as late as the 60s. It can also result from the surgical removal of both ovaries. A woman can still get pregnant during menopause until she has gone at least 12 months without menstruating (a period).

Changes and symptoms include: a change in menstruation (periods may be shorter or longer, lighter or heavier, with more or less time in between); hot flashes and/or night sweats; trouble sleeping; vaginal dryness; mood swings; trouble focusing; and, less commonly, hair loss on the head but increased hair on the face. About 85% of women experiencing menopause will have hot flashes.

All women will experience menopause. Menopause is not considered a disorder and most women do not need treatment for it. However, if symptoms are severe, medications may be used to help alleviate symptoms.

Researchers have estimated that more than 1.3 million women in the United States and 25 million women worldwide experience menopause annually. There are about 470 million postmenopausal women worldwide, a number that is expected to increase to 1.2 billion by the year 2030.

Some women take hormone replacement therapy (HRT) to relieve the symptoms associated with menopause. HRT is medication containing one or more female hormones, commonly estrogen plus progestin (synthetic progesterone). HRT may also protect against osteoporosis. However, HRT also has risks. It can increase the risk of breast cancer, heart disease, and stroke. Certain types of HRT have a higher risk, and each woman's own risks can vary depending upon her health history and lifestyle.

Perimenopause: During perimenopause, the woman may begin to experience menopausal physical and emotional signs and symptoms, such as hot flashes and depression, even though they still menstruate. The average length of perimenopause is four years, but for some women this stage may last only a few months or continue for 10 years. Perimenopause ends the first year after menopause, when a woman has gone 12 months without having her period. Periods (menstruation) tend to be irregular during this time and may be shorter or longer or even absent.

Despite a decline in fertility during the perimenopause stage, individuals can still become pregnant. If the individual does not want to become pregnant, they should continue to use some form of birth control until menopause is reached.

Postmenopause:
Postmenopause is a time when most of the distress of the menopausal changes have faded. Hot flashes may seem milder or less frequent and energy, emotional, and hormonal levels may seem to have stabilized. During postmenopause, women are at a higher risk for developing osteoporosis (bone loss) and heart disease, due to the decrease in circulating estrogen. The postmenopausal phase begins when 12 full months have passed since the last menstrual period.

Menstrual changes: Many women experience irregular periods due to the changing hormone levels and the decreased frequency of ovulation (egg release). The changes may be subtle at first and then gradually become more noticeable. Common changes include short cycles (less than 28 days), bleeding for fewer days than usual, heavier than usual bleeding, lighter than usual bleeding, and missed periods.

Although menstrual irregularities are expected during menopause, menstrual changes can also be caused by conditions such as fibroids or pregnancy. Women who experience heavy bleeding (usually with clots), periods that come more often than every three weeks, spotting between periods, or bleeding after intercourse, should see their doctor or other healthcare provider.

After menopause, women no longer menstruate. Any woman who experiences vaginal bleeding after menopause should see her doctor or other healthcare provider. Hormone treatments can sometimes cause vaginal bleeding to resume.

Changes in the body during menopause are called climacteric symptoms. They include hot flashes, skin and hair changes, and vaginal changes.

Hot flashes: As many as 85% of women experience hot flashes during menopause. Hot flashes are vasomotor symptoms that cause a warm or hot flushed sensation that usually begins in the head and face and then radiates down the neck to other parts of the body. There may be red blotches on the skin. Each hot flash averages 2.7 minutes and is characterized by a sudden increase in heart rate, an increase in peripheral blood flow, which leads to a rise in skin temperature, and a sudden onset of sweating, particularly on the upper body. Hot flashes can occur before, during, or after menopause. Hot flashes can begin when a woman's cycles are still regular or, more commonly, as menopause approaches and her cycles become irregular. They usually last for less than a year following the last menstrual period, although some women continue to experience hot flashes five to ten years after menopause. Hot flashes can occur once a month, once a week, or several times an hour. They can happen any time of day or night. If they happen at night (such as night sweats), they can interrupt sleep and drench clothing and sheets. Loss of sleep can eventually lead to irritability and fatigue.

Skin and hair changes: The process of aging can cause many changes in the body that result in skin and hair changes. Estrogen helps keeps the skin smooth and moist. The loss of estrogen during menopause makes the skin dry, thin, lax, and transparent. The blood vessels are easier to see, and the skin bruises easily. The woman may experience growth of facial hair, but thinning of hair in the temple region.

Vaginal changes: Women may experience vaginal changes. In particular, the tissues of the vagina and vulva may become thin and dry (called vaginal atrophy), which can lead to itching and discomfort during sexual intercourse. In some women, vaginal dryness is the first sign of menopause.

Other changes: Other changes that may occur during menopause includes: loss of bladder tone resulting in stress incontinence (leaking urine when coughing, sneezing, laughing, or exercise); headaches; dizziness; loss of some muscle strength and tone; increasing loss of bones, increasing the risk for osteoporosis; increasing risk for a heart attack when estrogen levels drop (however, the addition of estrogen as a prescribed medication after menopause can lead to an increase in heart attack and stroke); emotional changes associated with menopause such as irritability, mood changes, lack of concentration, difficulty with memory, tension, anxiety, and depression; and insomnia that may result from hot flashes that interrupt sleep.

A doctor will review the woman's medical history and perform a physical examination, including a pelvic exam. During the pelvic exam, a doctor will check for any abnormalities in the reproductive organs and look for indications of infection. There are no unique physical findings or laboratory tests to positively diagnose menopause.

The signs and symptoms of menopause, such as hot flashes and mood swings, are enough to tell most women they have begun going through the transition. Under certain circumstances, a doctor may check the level of follicle-stimulating hormone (FSH) and estrogen (estradiol) with a blood test. As menopause occurs, FSH levels increase and estradiol levels decrease. A doctor may also recommend a blood test to determine the level of thyroid-stimulating hormone, as hypothyroidism (low thyroid hormone levels) can cause symptoms similar to those of menopause, such as swelling, mood changes, and hot flashes.

The medical history and physical examination involve an evaluation of the symptoms and when they occur in relation to menstruation. Many healthcare providers advise women to keep a diary of menstrual cycles and the physical and psychological changes they experience over the course of several months. The menstrual diary provides clues to the physician and helps women understand and cope with the changes.

Several chronic medical conditions tend to appear after menopause. By becoming aware of the following conditions, women can take steps to help reduce their risk.

Cardiovascular disease: When estrogen levels decline, the risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men. Risk-reduction steps for developing heart disease include stopping smoking, reducing high blood pressure, getting regular aerobic exercise, and eating a diet low in saturated fats and plentiful in whole grains, fruits, and vegetables.

Osteoporosis: During the first few years after menopause, women may lose bone density at a rapid rate, increasing their risk of osteoporosis. Osteoporosis is a condition that causes bones to become brittle and weak, leading to an increased risk of fractures. Postmenopausal women are especially susceptible to fractures of the hip, wrist, and spine. It is important for all women to get adequate calcium and vitamin D. It is recommended by healthcare professionals for postmenopausal women to have about 1,200-1,500 milligrams of elemental calcium and 800 I.U. (international units) of vitamin D daily. Healthcare professionals recommend regular exercise. Strength training and weight-bearing activities such as walking and jogging are especially beneficial in keeping the bones strong and healthy. It is important to check for the amount of elemental calcium on the supplement label.

Urinary incontinence: Urinary incontinence is the loss of bladder control. As the tissues of the vagina and urethra lose their elasticity, postmenopausal women may experience a frequent, sudden, strong urge to urinate, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing, or lifting (stress incontinence).

Weight gain: Many women gain weight during the menopausal transition. Individuals may need to eat less, perhaps as many as 200-400 fewer calories a day, and exercise more just to maintain their current weight.

Calcium management: Adequate calcium intake is important to prevent osteoporosis and bone fractures. Daily elemental calcium intake for postmenopausal women should be around 1,200 milligrams. Women should eat foods rich in calcium (such as dairy products, leafy green vegetables, tofu, calcium-fortified foods), as well as foods that promote calcium absorption. A glass of milk provides about 300 milligrams of calcium. Intake of foods that rob the bones of calcium, such as animal protein and salt, should be limited. Vitamin D helps the body absorb calcium. Fifteen minutes of sun exposure every day provides sufficient vitamin D. Foods such as fortified milk, liver, and tuna contain vitamin D. Women should ask their healthcare provider or nutritionist if they should take a vitamin D supplement.

Exercise: Exercise is an important part of preventative healthcare for postmenopausal women. By increasing cardiovascular fitness and strengthening the bones, exercise helps prevent heart disease and osteoporosis. Low impact, weight-bearing exercises, such as walking, jogging, tennis, racquetball, and dancing, are helpful. Women diagnosed with osteoporosis or cardiovascular disease should consult with their healthcare provider before initiating an exercise program.

Hormone replacement therapy: Hormone replacement therapy (HRT) uses estrogens and progestin (synthetic progesterone) to ease the symptoms of menopause. The hormones are available in a variety of forms: pills, vaginal creams, vaginal ring inserts, implants, injections, and patches worn on the skin.

HRT has many short-term and long-term side effects. It is important to weigh all of the potential benefits and risks, preferences, and needs before beginning HRT. The benefits and side effects vary considerably from woman to woman. Women who take HRT should be closely monitored by a healthcare professional to ensure that they benefit as much as possible from the hormone therapy. Sometimes, changing the dosage or the way it is administered can help to control side effects.

Minor side effects include bloating, breast tenderness, cramping, irritability, depression, and menstrual bleeding for months or years following menopause. More serious risks include: breast cancer - women who have not had a hysterectomy and use estrogen supplements are at increased risk for invasive breast cancer and cardiovascular disease - HRT causes an increased risk for stroke (neurological damage caused by a lack of oxygen to the brain), heart attack, and cardiovascular disease.

Endometrial cancer has been linked to high-dose estrogen supplements. Women who have not had their uterus removed are prescribed low doses of estrogen with progestin (progestin protects against endometrial cancer).

Women who take HRT are at increased risk for deep vein thrombosis (DVT or blood clots).

HRT may help to prevent or delay the development of many diseases, including: osteoporosis; Alzheimer's disease; colon cancer; macular degeneration - the leading cause of visual impairment in persons over age 50; urinary incontinence; and skin aging.

Various types and dosages of estrogen and progestin are available and the type of HRT often depends on particular symptoms. For example, women who experience vaginal dryness may opt for a vaginal cream or vaginal ring insert, both of which alleviate dryness. The vaginal ring insert can also help urinary tract problems. For women who suffer from hot flashes, pills or patches may be helpful.

Due to the potential health risks involved with taking HRT, doctors will prescribe the lowest possible dosage for the shortest period of time when treating symptoms of menopause. Topical application of progesterone is commonly used as an alternative to HRT, especially if vaginal dryness is present.

Hormonal medications:

Estrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Depending on the individual's personal and family medical history, a doctor may recommend estrogen in the lowest dose needed to provide symptom relief for the individual.

Conjugated estrogens: Conjugated estrogens are a mixture of estrogens prescribed to treat menopausal symptoms. The conjugated estrogens in Premarin® and Premarin Vaginal Cream® are obtained from pregnant mare urine. The conjugated estrogens in Cenestin® are synthetic.

Esterified estrogens: Esterified estrogens (Estratab®, Menest®) are estrogenic substances consisting of 75-85% natural estrogens and 15-25% equine (mare urine) estrogens. They are supplied in tablet form and are used to treat hot flashes and atrophic vaginitis and urethritis (infections due to thinning and drying of vaginal tissues).

Estradiol: Estradiol is one of the three major estrogens made by the human body and is the major estrogen secreted during the menstrual years. It is available as an oral pill (Estrace®), transdermal skin patch (Climara®, Estraderm®, Vivelle®), vaginal tablet (Vagifem®), and vaginal cream (Estrace Vaginal Cream®).

Estropipate (estrone): Estropipate is an estrogenic substance derived from estrone, one of the three major estrogens produced by the body. Estrone is produced from estradiol and is a less potent estrogen. It is available in pill form (Ogen®, Ortho-Est®) and prescribed to treat hot flashes and vaginal atrophy and to help prevent osteoporosis.

Ethinyl estradiol: Ethinyl estradiol (Estinyl®) is a synthetic nonsteroidal estrogen available as a tablet that is prescribed to treat hot flashes (vasomotor symptom). It is administered on a cyclical basis (such as three weeks on and one week off) with attempts to discontinue or taper at three to six month intervals.

Testosterone: Testosterone is one of the androgens or male hormones and is also produced by women. Testosterone contributes to muscle strength, appetite, well-being, and sex drive (libido). The level of testosterone falls rapidly after menopause, and some women take testosterone supplements in addition to estrogen and progestin as part of HRT. However, supplemental testosterone can produce side effects and has potentially serious risks. Common side effects include weight gain, acne, facial hair, and liver disease. Testosterone can exacerbate estrogen's carcinogenic effect on breast and uterine tissue.

Other medications:

Low-dose antidepressants: Venlafaxine (Effexor®) is an antidepressant in a group of drugs called selective serotonin and norepinephrine reuptake inhibitors (SSNRIs). Effexor® has been reported to decrease menopausal hot flashes. SSRIs may be helpful, including fluoxetine (Prozac®, Sarafem®), paroxetine (Paxil®), citalopram (Celexa®), and sertraline (Zoloft®). Side effects include drowsiness and fatigue.

Gabapentin (Neurontin®): Gabapentin (Neurontin®) is commonly used to treat seizures and for neuropathy (nerve pain), but it also has been reported to significantly reduce hot flashes. Side effects include drowsiness, sedation, blurred vision, nausea, vomiting, or tremor.

Bisphosphonates: Alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), and zoledronate (Zometa®) are approved by the U.S. Food and Drug Administration (FDA) for the prevention and treatment of osteoporosis in postmenopausal women. Alendronate is also approved for management of osteoporosis in men. Both alendronate and risedronate are approved for the prevention and treatment of steroid-induced osteoporosis in men and women. Bisphosphonates help slow down bone loss and have been shown to decrease the risk of fractures. All are taken on an empty stomach with water. Because bisphosphonates have the potential for irritating the esophagus, remaining upright for at least an hour after taking these medications is recommended by healthcare professionals. Alendronate and risedronate can be taken once a week, while ibandronate can be taken once a month. An IV form of ibandronate, given through the vein every three months, also has been FDA-approved for the management of osteoporosis. Another IV bisphosphonate being studied for osteoporosis is zoledronic acid or zoledronate (Zometa®). This form is injected once yearly.

Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if the individual has had acid reflux or ulcers in the past. If individuals cannot tolerate oral bisphosphonates, the doctor may recommend the periodic intravenous infusions of a bisphosphonate.

Use of bisphosphonates in women who are pregnant or breastfeeding is not well studied. Blood calcium levels in women who take bisphosphonates during pregnancy are usually monitored. Individuals using ibandronate injection will have blood levels of creatinine measured prior to each dose to determine kidney function. Creatinine is measured using blood tests.

Selective estrogen receptor modulators (SERMs): Selective estrogen receptor modulators (SERMS) mimic the positive effects of estrogen on bones without some of the serious side effects such as breast cancer and stroke. Raloxifene (Evista®) decreases spine fractures in women, and is approved for use only in women at this time. Hot flashes are a common side effect of raloxifene, and individuals with a history of blood clots should not use this drug.

Vaginal estrogen: To relieve vaginal dryness, estrogen can be administered locally in the vagina using a vaginal tablet (Vagifem®), ring (Nuvaring®), or cream (Premarin® vaginal cream). This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse, and some urinary symptoms.

Calcium: Calcium is the nutrient consistently found to be the most important for attaining peak bone mass and preventing osteoporosis. Adequate vitamin D intake is required for optimal calcium absorption. Adequate calcium and vitamin D are deemed essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis. Multiple studies of calcium supplementation in the elderly and postmenopausal women have found that high calcium intakes can help reduce the loss of bone density. Studies indicated that bone loss prevention could be achieved in many areas, including ankles, hips, and spine. Although calcium and vitamin D alone are not recommended as the sole treatment of osteoporosis, they are necessary additions to pharmaceutical treatments. Treatment of postmenopausal osteoporosis should only be done under supervision of a qualified healthcare professional.

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat. Talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

Vitamin D: Adults with severe vitamin D deficiency lose bone mineral content ("hypomineralization") and experience bone pain, muscle weakness, and osteomalacia (soft bones). Treatment for osteomalacia depends on the underlying cause of the disease and often includes pain control and orthopedic surgical intervention, as well as vitamin D and phosphate binding agents.

Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use the essential oil or tinctures cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.

Soy: Soy (Glycine max) products containing isoflavones have been studied for the reduction of menopausal symptoms such as hot flashes. The scientific evidence is mixed in this area, with several human trials suggesting reduced number of hot flashes and other menopausal symptoms, but more recent research reporting no benefits. Overall, the scientific evidence does suggest benefits, although better quality studies are needed in this area in order to make a conclusion.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplementation.

Vitamin D: Without sufficient vitamin D, inadequate calcium is absorbed and the resulting elevated parathyroid (PTH) secretion causes increased bone resorption. This may weaken bones and increase the risk of fracture. Vitamin D supplementation has been shown to slow osteoporosis and reduce fracture, particularly when taken with calcium.

Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

Unclear or conflicting scientific evidence:

Acupuncture: Although some studies report beneficial results, currently there is not adequate available evidence to recommend for or against the use of acupuncture in the treatment of symptoms of menopause such as hot flashes. High quality clinical research is needed to make a conclusion.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.

Belladonna: Bellergal® (a combination of phenobarbital, ergot, and belladonna) has been used to treat menopausal symptoms like hot flashes. However, in human studies belladonna supplements have not shown effectiveness. More studies are needed.

Black cohosh: Black cohosh (Actaea racemosa, formerly known as Cimicifuga racemosa) is popular as an alternative to hormonal therapy in the treatment of menopausal symptoms such as hot flashes, mood disturbances, diaphoresis, palpitations, and vaginal dryness. Several studies have reported black cohosh to improve symptoms for up to six months, although the current evidence is mixed. The mechanism of action of black cohosh remains unclear and the effects on estrogen receptors or hormonal levels (if any) are not definitively known. Recent publications suggest that there may be no direct effects on estrogen receptors, although this is an area of active controversy. Safety and efficacy beyond six months have not been proven, although recent reports suggest safety of short-term use, including in women experiencing menopausal symptoms for whom estrogen replacement therapy is contraindicated. Nonetheless, caution is advisable until better-quality safety data are available.

Use of black cohosh in high-risk populations (such as in women with a history of breast cancer) should be under the supervision of a licensed healthcare professional. Use cautiously if allergic to members of the Ranunculaceaefamily such as buttercups or crowfoot. Avoid if allergic to aspirin products, non-steriodal anti-inflammatories (NSAIDs, Motrin®, ibuprofen, etc.), blood-thinners (like warfarin) or if history of blood clots, stroke, seizures, or liver disease. Stop use before surgery/dental/diagnostic procedures with bleeding risk and avoid immediately after these procedures. Avoid if pregnant or breastfeeding.

Black tea: Preliminary research suggests that chronic use of black tea may improve bone mineral density (BMD) in older women. Better research is needed to more clearly determine the effects of black tea for osteoporosis prevention.

Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances and insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism and irritability.

Boron: Animal and preliminary human studies report that boron may play a role in mineral metabolism, with effects on calcium, phosphorus, and vitamin D. However, research of bone mineral density in women taking boron supplements does not clearly demonstrate benefits in osteoporosis. Additional study is needed before a firm conclusion can be drawn.

Calcium: Calcium supplementation above the normal daily dietary intake has not been shown to reduce stress fractures. Further studies are needed to better determine the role of calcium in bone stress injury prevention.

Rickets and osteomalacia (bone softening) are commonly thought of as diseases due to vitamin D deficiency; however, calcium deficiency may also be another cause in sunny areas of the world where vitamin D deficiency would not be expected. Calcium gluconate is used as an adjuvant in the treatment of rickets and osteomalacia, as well as a single therapeutic agent in non-vitamin D deficient rickets. Research continues into to the importance of calcium alone in the treatment and prevention of this condition. Treatment of rickets and osteomalacia should only be done under the supervision of a qualified healthcare professional.

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat. Talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

Chromium: There is currently a lack of evidence for or against the use of chromium for the treatment of bone resorption and bone loss in postmenopausal women.

Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Copper: Supplementation with copper may be helpful in the treatment and/or prevention of osteoporosis, although early human evidence is conflicting. Further research is needed before clear conclusions can be drawn.

Avoid if allergic to copper. Avoid copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia. Avoid with genetic disorders affecting copper metabolism (e.g. Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis). Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6 milligrams/liter. Use cautiously with anemia, arthralgias, or myalgias. Use cautiously if taking birth control pills. Use cautiously if at risk for selenium deficiency. Doses that do not exceed the recommended dietary allowance appear to be safe during pregnancy and breastfeeding.

Creatine: Creatine is an amino acid that is found in the muscles. Early studies examining the effect of creatine in aging suggest that creatine may increase bone density when combined with resistance training. Further studies in which creatine alone is compared with placebo are needed.

Avoid if allergic or hypersensitive to creatine. Early research suggests that creatine may reduce muscle cramps that are often associated with hemodialysis. However, further studies are needed to confirm this claim. Avoid if taking diuretics (e.g. hydrochlorothiazide or furosemide). Use cautiously with asthma, diabetes, gout, kidney disease, liver disease, muscle problems, stroke, or with a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

DHEA: DHEA (dehydroepiandrosterone) is a hormone made in the human body and secreted by the adrenal gland. DHEA serves as precursor to male and female sex hormones (androgens and estrogens). Many different aspects of menopausal disorders have been studied using DHEA as a treatment, such as vaginal pain, hot flashes or emotional disturbances such as fatigue, irritability, anxiety, depression, insomnia, difficulties with concentration, memory, or decreased sex drive (which may occur near the time of menopause). Study results disagree and additional study is needed in this area. Additionally, the ability of DHEA to increase bone density is under investigation. Effects are not clear at this time.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or with anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Evening primrose oil: Primrose oil has been suggested as a possible treatment for osteoporosis. Well-designed human trials are needed before primrose oil can be recommended for osteoporosis therapy.

Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

Flaxseed: Flaxseed (Linum usitatissimum) and its derivative flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid, which is a biologic precursor to omega-3 fatty acids such as eicosapentaenoic acid. There is preliminary evidence from randomized controlled trials that flaxseed oil may help decrease mild menopausal symptoms. Additional research is necessary before a clear conclusion can be drawn.

Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with history of a bleeding disorder or with drugs that cause bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil®)), high triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding. Avoid with breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods.

Gamma linolenic acid (GLA): Gamma linolenic acid (GLA) is a dietary omega-6 fatty acid found in many plant oil extracts. Limited available study has examined the effect of GLA on menopausal hot flashes. No improvement in the number of hot flashed was noted as compared with placebo. Some clinical evidence suggests that GLA and eicosapentaenoic acid (EPA) enhance the effects of calcium supplementation for osteoporosis. More clinical studies are required to better determine effectiveness.

Use cautiously with drugs that increase the risk of bleeding like anticoagulants and anti-platelet drugs. Avoid if pregnant or breastfeeding.

Gamma oryzanol: Gamma oryzanol is a mixture of ferulic acid esters of sterol and triterpene alcohols, and it occurs in rice bran oil at a level of 1-2%, although it has been extracted from corn and barley oils as well. It is theorized that some of the health benefits from rice bran oil, namely its cholesterol-lowering effects, may be due to its gamma oryzanol content. Gamma oryzanol may reduce menopausal symptoms. However, these results must be viewed cautiously as a high placebo effect is associated with the treatment of menopausal symptoms. Additional study is needed in this area to better determine gamma oryzanol's effect on menopausal symptoms.

Avoid if allergic/hypersensitive to gamma oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners), central nervous system (CNS) suppressants, growth hormone, drugs or herbs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering or thyroid drugs, or herbs or supplements with similar effects. Use cautiously with diabetes, hypothyroidism, hypoglycemia, hyperglycemia and high cholesterol. Avoid if pregnant or breastfeeding.

Ginseng: Although ginseng (Panax ginseng) has been used for menopausal symptoms, evidence from a small amount of research is unclear in this area. Some studies report improvements in depression and sense of well-being, without changes in hormone levels.

Avoid with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Green tea: Green tea supplements are made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. A study conducted in healthy postmenopausal women showed that a morning/evening menopausal formula containing green tea was effective in relieving menopausal symptoms including hot flashes and sleep disturbances. Further studies are needed to confirm these results.

Green tea supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin®). Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease. Caffeine-free green tea supplements are available.

Hops: When used in combination with other products, hops may help alleviate menopausal symptoms, such as hot flashes and difficulty sleeping, because it has estrogen-like activity. However, until more well-designed studies are performed, a strong recommendation cannot be made.

Hops may cause drowsiness, therefore, caution is advised when operating an automobile or heavy machinery. Hops supplements are not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Horsetail: Silicon may be beneficial for bone strengthening. Because horsetail (Equisetum arvense) contains silicon, it has been suggested as a possible natural treatment for osteoporosis. Preliminary human study reports benefits, but more detailed research is needed before a firm recommendation can be made. People with osteoporosis should speak with a qualified healthcare provider about possible treatment with more proven therapies.

Avoid if allergic or hypersensitive to horsetail or nicotine. Avoid with a history of chronic alcohol abuse, malnutrition, and kidney disorders. Use cautiously with abnormal heart rhythms, diabetes, gout, neurological disorders, and osteoporosis. Avoid in children. Avoid if pregnant or breastfeeding.

Hypnotherapy: Early evidence shows that hypnotherapy may be beneficial in the treatment of hot flashes and may improve quality of life in women with menopausal disorders. Further research is needed.

Kudzu: Kudzu (Pueraria lobata) originated in China and was brought to the United States from Japan in the late 1800s. It is distributed throughout much of the eastern United States and is most common in the southern part of the continent. Kudzu contains chemicals called isoflavones, which are reported to have estrogenic activity. There is conflicting evidence regarding the effects of kudzu on menopausal symptoms. Additional study is needed to clarify these results.

Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Use cautiously if taking anticoagulants/anti-platelet and blood pressure lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, or methotrexate. Well-designed studies on the long-term effects of kudzu are currently unavailable. Avoid if pregnant or breastfeeding.

Milk thistle: An herbal preparation containing milk thistle may be effective in decreasing menopausal symptoms. However, milk thistle alone has not been researched.

Use cautiously if allergic to plants in the aster family (Compositea or Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

Phosphates, phosphorus: Early research shows that high amounts of phosphorus may have negative effects on bone density. This is because phosphorus decreases bone formation and increases bone resorption. Additional study is needed in this area.

Physical therapy: Supervised or home-based physical therapy has been used in combination with resistance and endurance training in physically frail elderly women taking hormone replacement therapy to improve bone density. Although early study is promising, more studies are needed in this area.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Pomegranate: There is currently not enough evidence to support the use of pomegranate in the reduction of menopausal symptoms.

Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root, and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.

Red clover: Red clover (Trifolium pratense) is a legume, which like soy, contains "phytoestrogens" (plant-based chemicals that are similar to estrogen, and may act in the body like estrogen or may actually block the effects of estrogen). Laboratory research suggests that red clover isoflavones have estrogen-like activity. However, there is no clear evidence that isoflavones share the possible benefits of estrogens (such as effects on bone density). Red clover isoflavones are proposed to reduce menopausal symptoms (such as hot flashes) and to serve as a possible alternative to hormone replacement therapy (HRT). However, most of the available human studies are poorly designed and short in duration. As results of published studies conflict with each other, more research is needed before a clear conclusion can be drawn.

It is not clear if red clover isoflavones have beneficial effects on bone density. Most studies of isoflavones in this area have looked at soy, which contains different amounts of isoflavones, as well as other non-isoflavone ingredients. More research is needed to better understand the effects of red clover on osteoporosis.

Avoid if allergic to red clover or other isoflavones. Use caution with hormone replacement therapy (HRT) or birth control pills. Use caution with history of a bleeding disorder, breast cancer, or endometrial cancer. Use caution with drugs that thin the blood. Avoid if pregnant or breastfeeding.

Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Currently, there is not enough evidence to support the use of reflexology for treating hot flashes and other menopausal symptoms.

Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. There is promising early evidence from human trials supporting the use of relaxation techniques to reduce menopausal symptoms,although effects appear to be short-lived. Better quality research is necessary before a firm conclusion can be drawn.

Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

Soy: It has been theorized that phytoestrogens in soy (such as isoflavones) may prevent post-menopausal bone loss and reduce the risk of osteoporosis. However, more research is needed before a conclusion can be made.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplementation.

St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions. The most common modern-day use of St. John's wort is the treatment of depression. Although St. John's wort supplements have been used with effectiveness in treating depression associated with menopause, there is a lack of high quality human studies supporting the use of St. John's wort for peri-menopausal symptoms.

St. John's wort interferes with the way the body processes many drugs using the liver's "cytochrome P450" enzyme system. As a result, the levels of these drugs may be increased in the blood in the short-term (causing increased effects or potentially serious adverse reactions) and/or decreased in the blood in the long-term (which can reduce the intended effects). Examples of medications that may be affected by St. John's wort in this manner include carbamazepine, cyclosporin, irinotecan, midazolam, nifedipine, birth control pills, simvastatin, theophylline, tricyclic antidepressants, warfarin, or HIV drugs such as non-nucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors (PIs). The U.S. Food & Drug Administration (FDA) suggests that patients with HIV/AIDS on protease inhibitors or non-nucleoside reverse transcriptase inhibitors avoid taking St. John's wort. Avoid if allergic or hypersensitive to plants in the Hypericaceae family. Rare allergic skin reactions like itchy rash have been reported. Avoid with organ transplants, suicidal symptoms, or before surgery. Use cautiously with history of thyroid disorders. Use cautiously with diabetes or with history of mania, hypomania (as in Bipolar Disorder), or affective illness. Avoid if pregnant or breastfeeding.

Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility, and strength. Preliminary research suggests that tai chi may be beneficial in delaying early bone loss in postmenopausal women and preventing osteoporosis. Additional evidence and long-term follow-up is needed to confirm these results.

Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

Traditional Chinese medicine (TCM): Traditional Chinese medicine (TCM) herbs are commonly used for menopausal symptoms such as hot flushes. Evidence is mixed. More studies are needed to explore the possible benefit of TCM herbs in menopausal symptoms.

Chinese herbs can be potent and may interact with other herbs, foods, or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ephedra (ma huang). Avoid ginseng if pregnant or breastfeeding.

Valerian: Valerian root (Valerian officinalis) has been used as a sedative and anti-anxiety treatment for more than 2,000 years. There is currently not enough available scientific evidence on the use of valerian for menopausal symptoms.

Caution is advised when taking valerian supplements, as numerous adverse effects including drowsiness and drug interactions are possible. Caution is also advised when operating heavy machinery or an automobile if taking valerian supplements. Valerian is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. A study of oral vitamin E reports a very small reduction in frequency of breast cancer-related hot flashes (approximately one less hot flash per day), but no preference among patients for vitamin E over placebo.

Vitamin E supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin®). Avoid if allergic or hypersensitive to vitamin E. For short periods of time, vitamin E supplementation is generally considered safe if taken at doses lower than the recommended dietary allowance (RDA). Avoid with retinitis pigmentosa (loss of peripheral vision).

Vitamin K: Vitamin K appears to prevent bone resorption, and adequate dietary intake is likely necessary to prevent excess bone loss and for osteoporosis prevention. Elderly or institutionalized patients may be at particular risk and adequate intake of vitamin K-rich foods should be maintained. Unless patients have demonstrated vitamin K deficiency, there is no evidence that additional vitamin K supplementation is helpful.

Avoid if allergic or hypersensitive to vitamin K. Injection into the muscle or vein should only be done by a healthcare professional; many serious side effects have occurred after injection. Menadiol (type of vitamin K that is not available in the United States) should be avoided with glucose-6-phosphate dehydrogenase deficiency. Conditions that interfere with absorption of ingested vitamin K may lead to deficiency, including short gut, cystic fibrosis, malabsorption (various causes), pancreas or gall bladder disease, persistent diarrhea, sprue, or ulcerative colitis. Avoid if pregnant. Use cautiously if breastfeeding.

Wild yam: It has been hypothesized that wild yam (Dioscorea villosa and other Dioscorea species) possesses dehydroepiandrosterone (DHEA)-like properties, and acts as a precursor to human sex hormones such as estrogen and progesterone. Based on this proposed mechanism, extracts of the plant have been used to treat menopausal symptoms such as hot flashes and headaches. However, these uses are based on a misconception that wild yam contains hormones or hormonal precursors - largely due to the historical fact that progesterone, androgens, and cortisone were chemically manufactured from Mexican wild yam in the 1960s. It is unlikely that this chemical conversion to progesterone occurs in the human body. The hormonal activity of some topical wild yam preparations has been attributed to adulteration with synthetic progesterone by manufacturers, although there is limited evidence in this area.

Avoid wild yam if allergic or hypersensitive to wild yam or any member of the Dioscorea plant family. Use cautiously with a history of hormone-sensitive conditions (e.g. breast cancer or endometrial cancer), asthma, blood clots, stroke, or diabetes. Avoid if pregnant or breastfeeding.

Yoga: Early evidence showed mixed results regarding yoga's effect on menopausal symptoms. Although early results are promising, more research is needed in this area.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Fair negative scientific evidence:

Boron: It has been proposed that boron affects estrogen levels in post-menopausal women. However, preliminary studies have found no changes in menopausal symptoms.

Dong quai: Dong quai (Angelica sinensis), also known as Chinese Angelica, has been used for thousands of years in traditional Chinese, Korean, and Japanese medicine. It remains one of the most popular plants in Chinese medicine, and is used primarily for health conditions in women. Dong quai is used in traditional Chinese formulas for menopausal symptoms. It has been proposed that Dong quai may contain "phytoestrogens" (chemicals with estrogen-like effects in the body). However, it remains unclear from laboratory studies if Dong quai has the same effects on the body as estrogens, blocks the activity of estrogens, or has no significant effect on estrogens.

Dong quai supplements may increase the risk of bleeding in sensitive individuals, such as those taking medications to reduce blood clotting, including aspirin and warfarin (Coumadin®). Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in medicinal doses is not known. Long-term studies of side effects are lacking. Avoid if allergic/hypersensitive to Dong quai or members of the Apiaceae /
Umbelliferae family (like anise, caraway, carrot, celery, dill, parsley). Avoid prolonged exposure to sunlight or ultraviolet light. Use cautiously with diabetes, glucose intolerance or hormone sensitive conditions (like breast cancer, uterine cancer or ovarian cancer). Do not use before dental or surgical procedures. Avoid if pregnant or breastfeeding.

Evening primrose oil: Available studies do not show evening primrose (Oenothera biennis) oil to be helpful with flushing or bone metabolism during menopause. Larger, well-designed study is needed.

Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

Menopause begins naturally when the ovaries start making less estrogen and progesterone, the hormones that regulate menstruation. The process usually begins in a woman's late 30s. By that time, fewer potential eggs for fertilization are found in the ovaries each month, and ovulation is less predictable. Progesterone (the hormone that prepares the body for pregnancy) levels drop and fertility declines. These changes are more pronounced in the 40s, as are changes in menstrual patterns. The woman's period may become longer or shorter, heavier or lighter, and more or less frequent. Eventually, the ovaries cease to function and there are no more periods. It is possible, but very unusual, to menstruate every month right up to the last egg is released, although a gradual tapering off is more common.

Early menopause is associated with the following risk factors: smoking; nulliparity (never carrying a child to full term); medically treated depression; exposure to toxic chemicals (such as pesticides); and treatment of childhood cancer with pelvic radiation or chemotherapy.

Menopause is usually a natural process. But certain surgical or medical treatments or medical conditions can bring on menopause earlier than expected. An oophrectomy (also called ovariotomy) is the surgical removal of the ovaries. Oophorectomies are most often performed in women due to ovarian cysts or cancer, prophylactially to reduce the chances of developing ovarian cancer or breast cancer, or in conjunction with the removal of the uterus. A hysterectomy is a surgical procedure to remove the uterus, but not the ovaries. A hysterectomy usually does not cause menopause. Although women no longer have periods, their ovaries still release eggs and produce estrogen and progesterone. However, surgery that removes the uterus and the ovaries (called a total hysterectomy and bilateral oophorectomy) does cause menopause, without any perimenopausal phase. Instead, periods stop immediately and hot flashes and other menopausal signs and symptoms appear. Research suggests that women that have their ovaries removed are at a decreased chance of developing breast cancer, ovarian cancer, and endometriosis.

Chemotherapy and radiation cancer therapies can induce menopause, causing symptoms such as hot flashes during the course of treatment or within three to six months.

Fortunately, many of the signs and symptoms associated with women's hormonal imbalances are temporary. Take these steps to help reduce or prevent the unwanted symptoms of menopause.

Decreasing hot flashes: Hot Flashes are caused by rapid decreases in estrogen levels. Unfortunately hot flashes cannot be prevented. However, they can be helped and made less uncomfortable. Techniques that can help individuals deal with hot flashes include: wearing loose clothing and dressing in layers so the layers of clothing can be peeled off during a hot flash; wearing fabrics that absorb moisture and dry quickly; avoiding foods that may trigger hot flashes, such as hot drinks and spicy foods; splashing the face with cool water at the start of a flash; and avoiding stress.

Optimizing sleep: Healthcare professionals recommend avoiding caffeine, especially in the evening and at night. Exercise (during the day) can also help improve sleep. Relaxation techniques, such as deep breathing, guided imagery, and progressive muscle relaxation, can be very helpful.

Strengthening pelvic muscles: Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence. The exercises consist of the regular clenching and unclenching of the sex muscles that form part of the pelvic floor (sometimes called the "Kegel muscles").

Eating well: Eating a balanced diet that includes a variety of fruits, vegetables, and whole grains and that limits saturated fats, oils, and sugars is recommended by healthcare professionals. It is also recommended to consume 1,200-1,500 milligrams of elemental calcium and 800 I.U. (international units) of vitamin D a day. Eating smaller, more frequent meals each day may reduce bloating and the sensation of fullness.

A high protein diet or high coffee consumption increases calcium excretion and may increase the calcium needs for the body. Fiber, oxalates (in rhubarb, spinach, beets, celery, greens, berries, nuts, tea, cocoa), and high zinc foods (such as oysters and red meats) decrease absorption, requiring more calcium as a dietary supplement. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures, particularly in the first 10 years after menopause.

It is recommended to limit salt and salty foods to reduce bloating and fluid retention, choose foods high in complex carbohydrates, such as fruits, vegetables, and whole grains, and choose foods rich in calcium. If the woman cannot tolerate dairy products or is not getting adequate calcium in the diet, a daily calcium supplement may be needed.

Excessive alcohol has been associated with osteoporosis due to the degenerative metabolic effects of alcohol. Alcohol excess may inhibit calcium absorption and bone formation.

Weight control: Being underweight is a risk factor for osteoporosis. Staying within a healthy weight is important for individuals experiencing menopause.

Smoking cessation: Smoking increases the risk of heart disease, stroke, osteoporosis, cancer, and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It is never too late to benefit from stopping smoking. Smokers lose bone more rapidly than nonsmokers. Among 80 year olds, smokers have up to 10% lower bone mineral density, which translates into twice the risk of spinal fractures and a 50% increase in risk of hip fracture. Fractures heal slower in smokers, and are more apt to heal improperly.

Regular exercise: It is recommended by healthcare professionals to get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis, and other conditions associated with aging in women. More vigorous exercise for longer periods may provide further benefit and is particularly important if the individual is trying to lose weight. Exercise can also help reduce stress.

Regular checkups: A doctor can advise the individual about mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing, and other screening tests.

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.